Hebrew High Registration - ValleyChabad.org

Please fill out ALL fields of this form.
If you have any questions or concerns you'd like to discuss, please contact us.
We look forward to a wonderful year of learning and growth.
One registration form is needed per child.
Parent information
Father's Name*

First Name Last Name
Father's Cellphone*

Area Code Phone Number
Father's E-mail*
Mother's Name*

First Name Last Name
Mother's Cellphone*

Area Code Phone Number
Mother's E-mail*
Home Phone

Area Code Phone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Full Name of Parent Filling Out Form*

First Name Last Name
Primary contact E-mail**
Information Updates*

My information is the same from last year.I have to update some information in the text box below.
Updated Information

Please list any changes here.
Student information
Number of Children to be Enrolled:*
1) Full Name*

First Name Last Name
1) Hebrew Name*
1) Birth Date*

Month Day Year
1) Medical: allergies or medical conditions
1) Where did you attend Hebrew School?
1) Grade Entering*
1) Session you are registering for?*
Second Child
2) Full Name*

First Name Last Name
2) Hebrew Name*
2) Birth Date*

Month Day Year
2) Medical: allergies or medical conditions/
2) Where did you attend Hebrew School?
2) Grade Entering*
2) Session you are registering for?*
Third Child
3) Full Name*

First Name Last Name
3) Hebrew Name*
3) Birth Date*

Month Day Year
3) Medical: allergies or medical conditions/
3) Where did you attend Hebrew School?
3) Grade Entering*
3) Session you are registering for?*
In case of Emergency

If we can't reach you.
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad Hebrew School to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in Chabad Hebrew School activities and that these pictures may be used for marketing purposes.
Medical Authorization*

Yes, I/We Accept
Initial*
Emergency contact 1* Name & phone
Emergency contact 2* Name & phone
Payment
Total

$0.00

Payment* Card will be charged on your selected schedule above.

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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Parent information

Student information

Second Child

Third Child

In case of Emergency

Payment

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